.

A study of the frequency of deaths resulting from the use of drugs and chemicals in Los Angeles County in the period 1947 - 1980 indicated that there was a substantial increase in the number of such deaths in 1968/69. This trend continued until 1976/77 when the number of deaths decreased, and the declining trend continued until 1979/80. An additional study in the period 1974 - 1981, based on the analyses of 35 drugs in biological samples taken in autopsies, showed that those drugs were more often present in overdose cases of death than in drug-related cases of death where drugs were not directly responsible for the occurrence of death. Ethanol and phencyclidine were, however, more frequently found in drug-related cases of death.

Drug abuse has been a social problem for many years; but over the past 15 years it has become a serious problem in the United States of America, especially in urban areas such as Los Angeles County.

Two studies on drug use trends among methadone maintenance patients and probationers in Los Angeles County, covering the period 1975 - 1980, have been published [1, 2]. The scope of those studies was, however, too narrow to get an overall picture. This paper presents the results of two broader-based studies carried out in Los Angeles County with the aim of supplementing the results obtained in the two earlier studies.

The first of the studies was undertaken in order to examine the frequency of death as a result of the use of drugs and chemicals in Los Angeles County during the period 1974 - 1980.

The second study analysed the relationship of drugs and death over the period 1974 - 1981. It covered both overdose cases of death, and drug related cases in which drugs were not directly responsible for the occurrence of death. The study focused on the frequency of occurrence of 35 of the drugs most commonly found in biological samples taken from the victims, and does not indicate whether or not they were a factor in death. The pathologists who performed autopsies in both overdose cases of death and drug-related cases of death requested analyses of the drugs involved. Human biological samples were analysed for drugs and poisons by procedures adopted from other authors
[
3] -
[
15] . Gas chromatography was the primary analysis tool, while complementary analyses were performed using gas chromatography/mass spectrometry, thin-layer chromatography, colorimetry, ultraviolet spectrometry, and radioimmunoassay. These methods have been found quite capable of measuring drug concentrations in biological samples with accuracy and precision
[
16] .

Table 1 shows both the number of deaths as the result of the use of drugs and chemicals and the rates per 100,000 population in Los Angeles County during the period 1947 - 1980. There was a slight overall increase from 1947/48 to 1967/68. Then, a substantial increase (66 per cent) occurred in 1968/69 compared with the previous fiscal year. This increase may reflect the beginning of the drug culture which developed on the college campuses in the late 1960s and the early 1970s. A substantial decrease in the number of deaths began in 1976/77 and the declining trend continued in subsequent years. These findings parallel the results obtained in a study indicating a decrease in drug use among the Los Angeles County probationers in the period 1976 - 1979
[
2] . The reasons for the decrease are not clear, although the decreasing popularity of drugs and the increasing popularity of alcohol occurring in the county might, at least to a certain extent, account for such a decrease.

The frequency of occurrence of the 35 most commonly found drugs was studied in biological samples of drug overdose cases of death and drug related cases of death in the period 1974 - 1981 (table 2). It should be noted that the occurrence of a given drug in the biological samples of the victim as

Table 1

Deaths due to drugs and chemicals in Los Angeles County, 1947-1980

1947/48

3747000

297

7.9

1948/49

3952000

347

8.8

1949/50

4090000

280

6.9

1950/51

4172220

311

7.5

1951/52

4302415

328

7.6

1952/53

4511737

333

7.4

1953/54

4676863

320

6.8

1954/55

4890567

398

8.1

1955/56

5085864

393

7.7

1956/57

5290246

417

7.9

1957/58

5507429

384

7.0

1958/59

5709011

395

6.9

1959/60

5919368

453

7.7

1960/61

6068148

396

6.5

1961/62

6337000

491

7.8

1962/63

6469000

605

9.4

1963/64

6604000

634

9.6

1964/65

6723000

629

9.4

1965/66

6814000

558

8.2

1966/67

6880000

507

7.4

1967/68

6941000

630

9.1

1968/69

7001000

1044

14.9

1969/70

7044721

1139

16.2

1970/71

7032075

1359

19.3

1971/72

7090452

1152

16.3

1972/73

7098826

1045

14.7

1973/74

7000679

1060

15.1

1974/75

6992299

1080

15.4

1975/76

7018603

1195

17.0

1976/77

7042538

943

13.4

1977/78

7083431

846

11.9

1978/79

7146500

696

9.7

1979/80

7441302

501

6.7

recorded in this study does not mean that the drug found was necessarily a causative factor of death. For example, some fatal overdose cases were the result of drug combinations. In some overdose cases several drugs had been taken, therapeutically or otherwise, but only one in sufficient quantity to be called an overdose. In still other overdose cases, an additional drug such as lidocaine might have been administered in attempts to revive the victim or to counteract the effects of the drug taken in overdose. It should also be noted that some of the drugs detected and indicated in table 2 may be metabolities of other drugs taken before death. Similar considerations apply in drug related cases of death.

Frequency of the occurrence of 35 analysed drugs in biological sampIes taken during autopsies of death cases
a, Los Angeles County, 1974-1981;

Table 2

Drugs found in overdose cases of death

Drugs found in drug-related cases of death

Drug

1974

1975

1976

1977

1978

1979

1980

1981

1974

1975

1976

1977

1978

1979

1980

1981

Morphine

450

567

387

127

120

85

72

165

53

43

44

56

49

41

40

42

Codeine

82

87

99

119

119

90

120

166

4

5

6

35

34

39

36

34

Methadone

12

19

16

14

16

25

20

27

3

0

1

9

7

4

7

6

Propoxyphene

70

83

71

97

66

35

39

45

10

8

10

16

10

7

5

8

Meperidine

1

9

4

15

4

2

2

5

0

2

4

3

1

1

0

1

Pentozocine

3

7

7

13

7

2

3

l

0

0

1

2

1

0

0

3

Phencyclidine

0

0

5

13

19

26

11

16

0

0

14

49

102

63

93

122

Cocaine

1

7

11

10

11

16

23

24

0

0

0

3

6

5

9

11

Lidocaine

7

8

9

8

5

8

17

21

0

12

31

2

11

6

16

8

Amphetamine

10

4

3

3

2

4

1

1

5

0

2

1

0

0

2

l

Caffeine

0

21

29

33

23

20

18

27

0

5

67

6

5

4

4

3

Diphenhydramine

3

9

9

12

4

1

4

11

0

0

6

4

2

2

3

8

Doxepin

12

13

20

3

25

26

18

19

3

5

2

9

l

5

5

3

Imipramine

15

9

20

11

15

15

11

6

1

2

2

2

0

0

1

2

Desipramine

0

0

0

12

8

1

15

7

0

0

0

2

0

0

0

0

Amitriptyline

36

73

82

70

73

54

39

66

2

9

10

19

13

11

8

5

Nortriptyline

0

0

0

8

13

6

10

7

0

0

0

0

0

0

0

0

Salicylate

8

12

14

16

10

15

20

20

2

0

2

1

3

4

4

0

Phenacetin

2

8

13

27

25

9

15

11

0

0

2

8

1

1

3

1

Acetaminophen

0

0

0

10

18

14

18

38

0

0

0

0

4

5

6

2

Barbiturates

476

527

462

416

334

235

230

209

340

189

221

260

152

131

129

83

Diazepam

101

98

45

88

74

23

18

36

14

17

7

25

27

9

11

13

Chlordiazepoxide

7

20

11

7

6

2

6

1

1

3

2

1

3

0

0

0

Flurazepam

3

6

7

12

12

5

14

10

0

0

1

0

0

3

2

2

Ethanol

355

522

367

256

182

167

166

193

1206

1068

1210

1381

1590

1714

1903

2295

Dilantin

9

16

12

9

4

0

2

4

6

11

5

10

7

4

9

2

Glutethimide

17

14

21

19

21

11

15

30

2

4

2

3

3

0

0

4

Meprobamate

25

31

23

23

28

13

11

15

6

10

6

4

1

7

3

2

Carisoprodol

3

8

1

4

5

2

4

1

0

2

2

1

0

0

0

0

Methaqualone

15

14

10

17

23

14

6

14

1

1

12

9

10

6

6

13

Thioridazine

12

26

18

17

10

9

7

0

11

9

5

17

5

1

4

0

Chlorpromazine

10

17

7

14

7

3

9

2

3

1

5

5

2

0

0

0

Ethclorvynol

27

23

58

30

54

33

11

21

5

2

14

8

5

5

5

4

ChloralHydrate

28

49

41

25

26

23

29

21

5

2

5

4

9

1

5

9

Methyprylon

18

24

13

9

7

9

3

2

2

2

0

1

2

1

0

1

aThe number indicating the frequency of the occurrence of a given drug does not necessarily indicate the number of cases of death as more than one drug could be found in one case of death.

An example is the case of a victim who was taking amitriptyline for depression, codeine for a cough, alcohol with dinner, and then took an overdose of methaqualone when committing suicide. Even though methaqualone was the drug that caused death, the presence of codeine, morphine, amitriptyline, nortriptyline and ethanol were recorded in table 2.

The analyses of drugs in overdose cases showed that the frequency of occurrence of the following drugs decreased substantially during the period 1974 - 1981: barbiturates, diazepam, ethanol, meprobamate, morphine (heroin), methaqualone, amphetamine, propoxyphene, imipramine, thioridazine, chlorpromazine, chloral hydrate and methyprylon. In contrast, the frequency of the occurrence of the following drugs increased : flurazepam, codeine, cocaine, phencyclidine and methadone.

In drug-related cases of death, the frequency of the occurrence of barbiturates decreased, while ethanol, codeine and phencyclidine increased.

A comparison of the data in the two cases showed that most drugs were more commonly found in overdose cases than in drug-related cases of death. In contrast, ethanol and phencyclidine were found much more frequently in drug-related cases than in overdose cases of death. It should be noted that there was a growing popularity of ethanol and phencyclidine in the same period. While lidocaine has increasingly been used as a drug of treatment in attempts to revive victims
[
17] , it was not implicated as a cause of death in any of the cases studied.

Table 3 shows that most overdose deaths occurred in the 20 - 39 age group. The death rate for teenagers decreased from 1970 to 1 980, while that for persons in their thirties increased. One possible explanation is that persons in their twenties when the drug culture peaked in the early 1970s were in their thirties at the time of the survey.

Table 3

Overdose cases of death in 1970, 1976 and 1980: Breakdown by age

(Percentage)

Age

Year

9 or below

10-19

20-29

30-39

40-49

50-59

60-69

70 or over

1970

0.3

11

32

16

14

12

8

6

1976

0.6

5

36

23

15

11

5

4

1980

0.6

3

32

29

15

9

6

5

The percentage of overdose deaths occurring among males were similar to those among females except in 1975, when it was considerably higher among males than females (see table 4).

Table 4

Overdose cases of death in 1970, 1975, 1977 and 1980 : Breakdown by sex

(Percentage)

Year

Male

Female

1970

50.9

49.l

1975

60.5

39.5

1977

54.5

45.5

1980

52.0

48.0

The number of overdose deaths that occurred in accidents increased over the period 1960 - 1980 (see table 5) with a slightly reversed trend at the end of the survey. The number of overdose deaths occurring in suicides during the same period showed a variation between the years studied but in general there was a decreasing tendency.

Table 5

Overdose cases of death by mode of death in 1960, 1970, 1976 and 1980 :

Breakdown by mode of death

(Percentage)

Year

Accident

Suicide

Undetermined

1960

20

79

1

1970

31

60

9

1976

64

35

1

1980

52

46

2

The percentages of overdose deaths among blacks and whites were greater than expected on the basis of their relative number in the country population. For Hispanics and Asians the percentages were lower (table 6).

Table 6

Overdose cases of death in 1970, 1975 and 1980: Breakdown by race and ethnic origin